Expert Commentary
Why FDA hearing on morcellation safety could drive innovation
Reaction from Cheryl Iglesia, MD, Advisory Panel Member, to FDA’s 2-Day Hearing
Vaginal hysterectomy is the preferred route to benign hysterectomy because it is associated with better outcomes and fewer complications than the laparoscopic and open abdominal approaches.1,2 Yet, despite superior patient outcomes and cost benefits, the rate of vaginal hysterectomy is declining.
According to the Nationwide Inpatient Sample, the use of vaginal hysterectomy declined from 24.8% in 1998 to 16.7% in 2010.3 In fact, more than 80% of surgeons in the United States now perform fewer than five vaginal procedures in a year.4
The increasing use of other minimally invasive routes, such as laparoscopy and robotics, indicates that most practicing surgeons and recent graduates are choosing these approaches over the vaginal route. In only 3 years, the rate of laparoscopy increased by 6% and robotics increased by almost 10%.3
Many surgeons assume that vaginal hysterectomy exists in a state of suspended animation, with nothing much changed in the way it has been performed over the past few decades. Further, vaginal surgery is difficult to teach and learn, given limitations in exposure and visualization, difficulty in securing hemostasis, and challenges in the removal of the large uterus and adnexae. As a result, vaginal hysterectomy often is thought, erroneously, to be indicated only in procedures involving a small and prolapsing uterus.
To increase the rate of vaginal hysterectomy, we can benefit from experience gained in laparoscopy and robotics—whether we are teachers or learners—while maintaining patient safety and containing costs.
In this article, I describe common challenges in vaginal hysterectomy and offer tools and techniques to overcome them:
- achieving and enhancing ergonomics, exposure, and visualization
- the need to work in a long vaginal vault
- the task of securing vascular and thick tissue pedicles when the introitus and vaginal vault are narrow.
The vaginal approach is less costly
Vaginal hysterectomy costs significantly less to perform than other approaches. At a tertiary referral center, vaginal hysterectomy costs approximately $7,000 to $18,000 per case less than laparoscopic, abdominal, and robotic hysterectomy.5 With declining use of vaginal hysterectomy and increasing use of more costly approaches, we face a health-care crisis.
Residents are inadequately trained to perform vaginal hysterectomy
Data reveal that not only are our recent graduates inadequately prepared to perform vaginal hysterectomy, but national health-care dollars and resources are depleted when surgeons choose to perform more costly approaches. As a result, many eligible patients end up deprived of the benefits of a single, concealed, and minimally invasive procedure.
The increase in laparoscopic and robotic approaches to hysterectomy has affected residency training. National case log reports from the Accreditation Council of Graduate Medical Education show that the number of vaginal hysterectomies performed by residents as “primary surgeons” decreased by 40%, from a mean of 35 cases in 2002 to 19 cases in 2012.6 A recent survey found that only 28% of graduating residents were “completely prepared” to perform a vaginal hysterectomy, compared with 58% for abdominal hysterectomy, 22% for laparoscopic hysterectomy, and 3% for the robotic approach.7
The rate of vaginal hysterectomy will continue to decline if we perform it in the same manner it was done 30 years ago. The current generation of practicing gynecologists and graduates is choosing to perform the procedure laparoscopically or robotically because of the advantages these technologies provide. It is time that we incorporate features from these minimally invasive approaches to streamline vaginal hysterectomy while maintaining patient safety and containing costs.
Challenges: Ergonomics, exposure, and visualization
In conventional vaginal surgery, the surgeon often is the person who has the best and, sometimes, the sole view. Two bedside assistants are required to hold retractors during the entire case, which can lead to fatigue and muscle strain. Poor lighting also can greatly limit visualization into the pelvic cavity.
Both laparoscopy and robotics provide a well-illuminated and magnified view, with three-dimensional images now available in both platforms. This view is projected to overhead monitors for the entire surgical team to see. Magnification of the pelvic anatomic structures and projection to an external monitor facilitate teaching and learning, better anticipation of the surgical and procedural needs, and overall patient safety.
From robotics, where ergonomics is exemplified, we also learn the importance of surgeon comfort during the procedure.
Solution #1: A self-retaining retractor
A self-retaining system such as the Magrina-Bookwalter vaginal retractor (Symmetry Surgical, Nashville, Tennessee) (FIGURE 1)
Solution #2: Seat the surgeon for an optimal view
With the patient in the lithotomy position and her legs in candy cane stirrups, the surgeon can be seated on a high chair so that the operative field is at the approximate level of the assistants’ view (FIGURE 2)
